If you want this printable copy, deposit Rs. 5/ in Bank of Maharashtra. Kasba Peth Br. -A/c No.

c/c 20037902622- IFP No. MAHB0000322 and then inform us by e-mail. On receipt of the e-mail and amoun, we shall send you the printable soft
copy of the form which you may print and use.

Form XXIX
[See Rule 250(d)]
Health Register
(In respect of persons employed in Building and others Construction work involving hazardous processes)
Name of the the Construction medical Officer / Medical Inspector.
(a) Mr _________________________________________________ from _________________________________________________ to _________________________________________________
(b) Mr _________________________________________________ from _________________________________________________ to _________________________________________________
(c) Mr _________________________________________________ from _________________________________________________ to _________________________________________________

If suspended Certified fit

Date of medical from work, If certificate
Date of to resume
Date of Reason for Raw examination by Results of state period of unfitness
employmen Nature of duty on with
Sr. Age (last leaving or leaving, material or certifying medical of or
No. Work No. Name of the building Sex Birthday) t of transfer to transfer or job or bi product Surgeon Medical examination suspension signature of suspension
present occupation Medical
other work discharge handled Inspector with issued to
work Inspector /
/CMO detailed worker
CMO
reasons
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1
2
3
4
5

Signature with date of Medical Inspector / CMO

Note : - (i) Column(8) - Detailed summaryof reason for transfer oe discharge should be stated.
(ii) Column(12) - should be pressed as fit/unfit/suspended.
HOUSE OF FORMS, Pune. Tel.: 24571065, 24572430 . E-mail: ajinkya@houseofforms.com AI-A0-0I